Transcript Mother Frances Hospital Regional Health Care Center ON THE

Mother Frances Hospital
Regional Health Care Center
ON THE CUSP: NO BSI
Update and Assessment
Hospital Acquired Infections: ICU
April 10, 2012
Presented in Webinar Format June 21, 2012
Trinity Mother Frances
Hospitals And Clinics
About Us
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Independent, faith-based Integrated Delivery System
MFH-Tyler: 404 Total Beds, 70 ICU Beds
25,000 annual inpatient admissions
2,600 annual deliveries
20,000 annual surgery volume
75,000 annual Emergency Care visits
2 Critical Access Hospitals
Affiliation w LTACH, Rehab hospitals
275 physician multi-specialties;
– on-site full-time (24/7/365) Intensivist program
– “4-bar” Leapfrog ICU Staffing score (2009, 2010, 2011; 2012 expected)
• 350,000 annual clinic visits
Central Line Associated Infections
Pre-CUSP
Improvements
All ICU'S by Quarter January 2006 - Present
14.0
#CLBSI/#CL Days x 1000
12.0
100 K
Lives
Quality in
Strategic
Plan
5M
Lives
Sentinel
Event
“Average”
Performance
Achieved
10.0
10.0
8.1
7.8
8.0
6.8
6.7
6.7
5.6
6.0
4.6
4.8
O/E: 1.4
4.3
4.5
4.0
2.7
2.0
‘observed” 13
“expected “ 9
5.3
6.1
3.1
2.8
2.3
‘observed” 40
“expected “ 18
O/E: 2.2
‘observed” 35
“expected “ 21
O/E: 1.7
2.2
‘observed” 33
“expected “ 8.5
1.5
O/E: 3.9
0.0
CL TMFHS
NNIS 50th Benchmark
2.3
1.7
1.8
1.2
0.6
Why we signed up for CUSP
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We
We
We
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We
We
We
We
have
have
have
have
have
checklists
protocols
order sets
CLABSI carts
PDCA
The ‘Swiss Cheese’ Model
of Accident Causation
Equipment
Procedures
People / Culture
Environment
Hazards
Harm
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don’t
don’t
don’t
don’t
have
have
have
have
the CULTURE
the STRUCTURE
ENGAGEMENT
PATIENT CENTERED-NESS
The CUSP Version
of Team Training
The CUSP Premise
• Leadership
CUSP Focuses
Here
• Climate
“Adaptive”
Work
• Culture
• Behavior
“Technical”
Work
• Outcomes
ON THE CUSP: NO BSI
THE MFH-Tyler GOAL IS:
ZERO CLABSI
ZERO VAP
IN ALL FOUR ICUs
For 6 consecutive months
BY JANUARY, 2012
FOREVER
The CUSP Program
Unit-Based Team Training
 Form an interdisciplinary unit-based team for EACH participating ICU
 Recruit Senior Leadership involvement (not just ‘support’)
 Recruit medical staff, medical staff leadership engagement
 Staff to view “The Science of Safety” video (97 of 112 attended)
 January 2011: started viewing in critical care residency
 January 2011: available on TMF intranet
 September 2011: Integrate into orientation of new hires to ICU, Float pool working ICU
 Measure Safety Culture of Unit(s); (97% response rate, n-122)
 Debrief staff on culture survey results.
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ENGAGE STAFF IN PROBLEM - SOLVING AND PROFESSIONAL ACCOUNTABILITY
 STAFF identify defects affecting care / distraction
 In 60- or 90-day cycles, learn from one defect… and fix it !!
 Periodic updates: Status of Identified Safety Issues
 Identify and engage group “Influence Leaders”.
 Implement Team Building Tools
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Root Cause “lite”; learn from defects
Daily (patient) Goals Checklist (nursing / medical staff)
Shift Briefing / “Huddle” (unit staff, unit leadership, medical staff)
Professional “shadowing”
Reliable physician contact information
Indicates ‘done’ or ‘continuing’
EXAMPLE
Scope of Work
CUSP 90-day Improvement Cycles
Neuro Critical Care
Round 1 CLABSI Insertion bundle, CLABSI maintenance bundle
Aug 2010
Physician order illegibility; conflicting orders, physician care coordination
Order entry, chart management (Unit Secretaries /PCA cross training)
Round 2 CLABSI Insertion bundle, CLABSI maintenance bundle (scrub-a-hub, dressing
Oct 2010
change standardization), general hand hygiene;
Fall maintenance; alarm integration; fall risk identification / interventions
Round 3 CLABSI insertion bundle, maintenance bundle, sterile port caps, scrub-a-hub
Jan 2011
end ‘y-siting)
Respectful communication , staff collegiality; “call out”
VAP Bundle; collaboration w/ Respiratory Care on oral hygiene.
ANNUAL CUSP CELEBRATION: STAFF Review accomplishments, set goals 2011
April 2011
Round 4
May 2011
Round 5
Aug 2011
Round 6
Nov 2011
Round 7
Jan 2012
VAP / CLABSI Bundles (“CALL OUT” violations in bundle management)
Staffing ‘grid’; anticipate pending admissions, provide coverage.
VAP / CLABSI Bundles (challenge patient need for device)
ICU competencies; list of required skills and mentors.
Increase staff engagement in CUSP initiative; instill accountabililty for outcomes
ICU competencies; list of required skills and mentors. .
CAUTI Best practice guidelines, ‘bundles’ for insertion and maintenance.
“Routine” urine cultures all ICU admission; establish POA status for UTI.
Impact of aggressive bowel management on CAUTI; prevention strategies
2010 CUSP Program In Review
SWOT Exercise
SWOT Analysis
CUSP Leadership Team
December 27, 2010
SWOT
Analysis
STRENGTHS
Recruiting increased engagement from staff
Large support system from bedside nurses to MDs
Teams are motivated to improve things
We have the tools to make it work
CUSP provides structure to work on specific processes
Open discussions about what can be improved
Created ‘safe’ spaces for frank discussions
Team members are open to learning
OPPORTUNITIES
Discuss CUSP more often w/ Senior Leadership
Staff level communication about Sr Exec Support
Expand CUSP activities to include other disciplines
Two-way communication between teams and
Senior Leadership
Improve communication of CUSP initiative(s)
Use the language of CUSP
Create accountability / ownership of CUSP activities
-Define core group of planners / communicators
Define “VISION”, what ‘success’ looks like
- Improving culture or ‘looking good’.
- Infection reduction vs culture creation
- Patient-centered decision making
Regular process date reporting
- Transparent data definitions
Continue to promote and create longevity
Establish follow-up / follow thru on initiatives
- Leaders to leaders,
- staff to leaders,
- leaders to staff
WEAKNESSES
Apathy between MD and RN staff toward CUSP
Changes in critical leadership positions
Some projects ‘over-reached’ for goals
Communication to non-CUSP member units
Communication to staff about CUSP goals
Inconsistency w/ team members at activities
Reliability of performance measures unclear
Divergent ‘visions’ of CUSP
(what does “success” look like?)
CUSP leadership planning effectiveness / time
THREATS
Changes in clinical / operational leadership
‘Unattainable’ goals leading to team frustration
Length of CUSP project (3 years); sustainable?
Change in corporate priorities
Ongoing crisis management vs pro-active building
Achieving ‘zero’ CLABSI rate; CAUTI rate.
Insufficient ‘change management’ skills
- Leadership development
- Staff development
Central Line Associated Blood Stream Infections (CLABSI)
All ICU'S by Month January 2006 -Present
18
16
2006
7.1 / 1,000 line-days
2007
5.4 / 1,000 line-days
2008
4.3 / 1,000 line-days
40 infections
5,604 line-days
35 infections
6,439 line-days
33 infections
7,680 line-days
2010
2009
1.6 / 1,000 line days
1.8 / 1,000 line-days
13 infections
22 "expected" (Tx )
7,091 line days
11 infections
9 "expected" (Tx)
6,891 line days
14
#CLI/#CL Days x 1000
12
2011
1.1 / 1,000 line days
2012 (3 mo)
1.8 / 1,000 line days
7 infections
6.6 "expected" (Tx)
6,175 line days
3 infections
1.9 "expected" (Tx)
1,716 line days
(6,864 annualized)
NEW HOSPITAL
RECORD
0
Total
CLABSI-free months
1
Total
CLABSI-free months
1
Total
CLABSI-free months
2
Total
CLABSI-free months
4
Total
CLABSI-free months
6
Total
CLABSI-free months
1
Total
CLABSI-free months
10
2011 Detail: CLABSI
Jan Neuro SC 1 5 days
Feb SICU IJ
26 days
Mar SICU IJ
4 days
Apr CICU 2 Fem, EMERG
Jul CICU Fem, CHILL
Sep CICU IFem, CHILL
8
2012 Detail: CLABSI
Jan Neuro PICC 9 days
Jan MICU FEM(3) 4 days
Mar SICU loc unk.
6
3.5
n=2
4
1.6
n=1
2
0
CL TMFHS
NHSN 50th Banchmark
TREND - ALL ICUs
RESULTS
2006-2011 “CENTRAL LINE
INFECTIONS”
Central Line Data 2006-2011
“CENTRAL LINE DAYS”
9 000
8 000
40
7680
7091
7 000
6 000
45
CUSP
6439
6891
35
40
CUSP
35
33
6175
30
5604
5 000
25
4 000
20
3 000
15
2 000
10
1 000
5
0
0
13
11
7
ALL ICUs
ALL ICUs
2006
2007
2010
2011
TREND?
Month / yr
Indication for
Catheter Use
Organism (line) Patient
Location
IAB counterpulsation
Klebsiella
Pneumoniae
HHICU
Acinetobacter
Baumannii
HHICU
Therapeutic
Hypothermia
MRSA+
enterococcus
species
HHICU
Coag-neg staph,
enterococcus
MICU
Length of Use
Therapeutic
Hypothermia
Jan 2012
PICC
9-days
Poor vascular
access
Coag-neg staph
Neuro ICU
Mar 2012
IJ, Quentin
Acute Renal
Dialysis
Klebsiella
Pneumoniae
SICU
April 2011
Line Insertion
Site
Femoral
-EMERGENT –
Not Replaced
July 2011
Femoral
-EMERGENT –
Not Replaced
Sept 2011
Femoral
Length of Use
Jan 2012
Femoral
BONUS : CUSP DELIVERABLE
VAP Data
Ventilator-days: All ICUs
5 000
4 500
4 000
VAP Data
VAP Infections: All ICUs
4664
4124
35
4177
3948
30
3646
3 500
3197
3 000
25
2 500
20
2 000
15
1 500
1 000
Excludes
CICU
Includes ALL ICUs
2008-resent
29
13
12
12
10
500
5
0
0
5
Total Ventilator Days
3
Total VAP Infections
2006
2007
2008
2009
2010
2011
PRELIMINARY RESULTS (3 mos)
Catheter Associated Urinary Tract Infections (CAUTI)
All ICUs Combined
16,0
2006
rate: 6.4/1000
expected: 3.1 / 1000
"O/E": 2.1
n=56
Device Days 8750
2007
rate: 4.7/1000
expected: 3.1 / 1000
"O/E": 1.5
n=50
Device Days : 10,598
2008
rate: 4.9/1000
expected: 3.1 / 1000
"O/E": 1.6
n=58
Device Days : 11,805
2009
rate: 2.4/1000
expected: 3.1 / 1000
"O/E": 0.8
n=24
Device Days : 10,123
2010
rate: 2.7/1000
expected: 3.1 / 1000
"O/E": 0.9
n=29
Device Days : 10,672
2011
rate: 4.1/1000
expected: 1.2 / 1000
"O/E": 3.4
n=43
Device Days : 10,548
CAUTI Incections per 1000 catheter-days
14,0
12,0
10,0
8,0
6,0
4,0
2,0
0,0
Unfavorable
Performance
Shift
2012 3 mo.
rate: 2.5/1000
expected: 1.3 / 1000
"O/E": 1.9
n=7 infections
(28 annualized)
Device Days : 2,754
(10,116 annualized)
“Secrets”
• Team ‘buy-in’
– Use formal and INFORMAL leaders’ influence
• Use the “powerful” and the “influential”
– WIIFM? (What’s in it for me?)
– Set expectations of behaviors (technical and personal)
• Decisions will be made…with or without you
– Celebrate successes
• Diminish the “Flavor Of The Month” expectation
– Set expectations with or without staff attendance
• “No show, no vote”
Challenges
“Secrets”
• Maintain HAI / Team Skills as a unit priority
– 45-day cycles, with mid-cycle check-ins
– Relevant defects discussed to completion
– Who, what, by when assignments
• Maintain HAI / Team Skills as a CORPORATE
priority
– Regular reporting to senior leadership
– Regular feedback as to barriers and facilitators
– ROI updates based on results
Mother Frances Hospital
Regional Health Care Center
Hospital Acquired Infections: ICU Devices
FY 2011 vs 2010
• Estimated Financial Impact ALL ICUs
– VAP Reduction
$157,890 savings
• 88 hospital-days saved
– CLABSI Reduction
$218,736 savings
• 91 hospital-days saved
– All Devices Combined
$376,626 savings
• 199 hospital-days saved
• Capacity created for 49 additional ICU admits
@ 4-day ICU LOS
24 –mos Total Estimated Savings
$823, 490
Thank You
Questions?